Ingrained habits, physician resistance are obstacles
According to recent data from the Joint Com-mission on Accreditation of Healthcare Organizations, compliance with the National Patient Safety Goals (NPSGs) is more than 94%, with one notable exception: the requirement to standardize abbreviations, which falls to 85% compliance.
"Overall, we have seen great improvements in decreasing the use of unapproved abbreviations," says Marie Gowdy, APRN-BC, lead clinical nurse specialist at NorthEast Medical Center in Concord, NC. "But we are nowhere close to meeting the 100% compliance required for Jan. 1, 2005."
The main problem is simply trying to get practitioners, including nurses, respiratory therapists, and physician’s assistants (PAs) out of the habit of writing the abbreviations they were taught, says Gowdy. "’QD’ continues to be our biggest problem," she adds.
The majority of hospital staff are working very hard on changing behaviors and are doing their best to achieve this NPSG, but there still are problems with compliance, reports Martha McKee, RN, MN, OCN, oncology manager at Good Samaritan Hospital in Puyallup, WA. "I think the major obstacle in achieving compliance is the ingrained habits of staff,"she says. "In some cases, nurses and physicians have been using these abbreviations in excess of 30 years."
This particular NPSG misses the "heart of the problem," according to McKee, which she says is legibility of orders and documentation. "If QD,’ QOD,’ and U’ are written legibly in a clearly defined order, there really isn’t a problem with the use of abbreviations."
Also, when physicians are writing orders, they concentrate on what their patients need, not on a prohibited list of abbreviations, McKee notes. "Likewise, when the secretaries or nurses are reading the orders written by the physician, they concentrate on carrying out the orders in a timely fashion, not on the prohibited abbreviations."
To improve compliance, use these strategies:
• Find creative ways to share list of unapproved abbreviations.
The do-not-use abbreviations are posted throughout the hospital units at Good Samari-tan, placed in patient charts, and printed on physician orders and progress notes, to help remind staff that these abbreviations are prohibited, says McKee. "We also have mouse pads with the list of prohibited abbreviations throughout the organization," she adds.
Small pocket cards with the unapproved list are given to practitioners, new clinical employees, residents, and nursing students at NorthEast.
At Saint Joseph’s Hospital of Atlanta, the do-not-use list is posted on the computer clinical system, printed in bright green lettering in front of every physician order section of the patient’s chart, listed in the hospital’s and physicians’ newsletter, and posted in the medical staff lounge and the bathrooms, according to Kathy Brandeis, RN, BSN, performance improvement/JCAHO coordinator.
• Address noncompliant software.
"The biggest problem we have is with the electronic version, because half of our chart is in the computer," she explains. "When your clinical computer vendor is not compliant with upgrading their software, we don’t have control over that."
The problem is that the number of characters for a given field was limited to six, which would not allow for the spelling out of "international units," or "every day" as per the Joint Commis-sion’s recommendations, says Brandeis.
"One thing that JCAHO has not made clear is that the list on how to word those abbreviations is a preferred list, but is not a mandated list," says Brandeis. The Joint Commission clarified this during a telephone conference call after the organization’s PPR was completed, she reports.
This meant that "INT UNIT" could be used instead of writing out "international unit," as long as the prohibited abbreviation "IU" was not used, Brandeis explains. Likewise, "QDAY" can be used instead of writing out "every day" as long as "QD" is not used," she says.
• Check forms and order sets.
The organization has more than 500 physician order sets, both on paper and in the computer system, since physicians do not use computerized physician order entry yet, says Brandeis. The medical records committee recently audited copies of every form to check for unapproved abbreviations and also to make sure that there is nothing written that says "continue or resume previous medication."
The revised medication management statements require that there be no blanket reinstatement of medications during the patient’s entire stay, explains Brandeis. "All medications must be written out, including medication dosage, route, and time," she says.
• Audit medication orders.
At Saint Joseph’s, the pharmacy director assigned two pharmacy students to audit 700 medication orders for unapproved abbreviations, Brandeis adds.
The three main problems were use of "U" for units, "QD," and no leading zero, she says. This information was presented to managers and directors, the nursing practice council, nursing performance improvement council, and nursing education council, with specific information as to who was compliant and who was not, and which abbreviations were the most problematic. The audits will be done twice a year, Brandeis adds.
If an unapproved abbreviation is used by a physician, nursing or pharmacy will tell him or her to clarify the written order and then rewrite it without the do-not-use abbreviations. The pharmacist will collaborate with the nurses to rewrite that order in its correct form, she says.
"Right now, this is a teaching approach and is not punitive. We try to drill down to find what particular specialty is doing this; then we do specific education for that group," Brandeis explains.
For instance, when it was discovered that an endocrinologist was writing "U" for units, the specific physician group was given feedback and copies of the list, she adds.
Although the organization’s audit focused only on medication orders, it’s important to remember that the requirement applies to all orders, Brandeis notes. "A few people did not realize that and thought it only pertained to medication orders."
• Educate staff.
"We have tried to empower staff to call and clarify any unapproved abbreviations, hoping that this will stimulate some change," Gowdy says. Staff have been educated about the importance of clear communication, both written and spoken, she adds. "We have showed them that the No. 1 root cause of most mistakes is related to communication. We give examples, such as actual handwritten orders that are not clear and the potential risks involved," she says.
In 2005, part of the required annual education for clinical staff will include a one-hour session on communication and how it relates to medical mistakes and prevention, Gowdy notes. "In these sessions, we will continue to talk about real and potential mistakes that have actually happened at our hospital and discuss how they might have been prevented. This will include an interactive exercise in verbal and written communication."
• Take corrective action as needed.
At NorthEast Medical Center, the medical staff office sends physicians a letter and copy of the hospital policy when a chart reviewer or pharmacist catches an unapproved abbreviation, Gowdy says. Pharmacy also sends orders with unapproved abbreviations to the medical staff office and to nursing leadership for follow-up and re-education, says Gowdy. "These strategies have been fairly effective, but not 100%," she says. Compliance has gone from 40% based on an open chart audit done in March 2004, to 86% when an open chart audit was done in June 2004.
The audits showed physicians are responsible for 38% of all unapproved abbreviations, followed by nursing (31%), CRNAs (15%), and PAs (3%). "QD, MS04, and no leading zero are the top three culprits," she says.
"At this point, we are kicking around the idea of tying abbreviations compliance to reappointment status," Gowdy says. "However, until JCAHO’s Abbreviations Summit occurs, we are holding off on this due to the chance of our unapproved list changing again."
All physician orders are monitored for the use of prohibited abbreviations, says McKee. The secretary circles the unapproved abbreviation and lets the patient’s nurse know that the physician must be contacted for a clarification of the order. "We try to cluster these calls to the physician to save time," she says.
For example, if a nurse has to report a patient’s temperature, the abbreviation will be clarified at that time, if necessary. "One of the most effective strategies is to try to catch the physician during rounds and get a clarification before he or she leaves the unit," she says.
The backup plan, should the secretary miss circling the unapproved abbreviation, is to have the pharmacist contact the physician for clarification, McKee explains. "This policing has created some angst and strained communication between physicians and nurses at times, but this is the method that was decided upon by the medication safety subcommittee," she says.
There have been a few instances where physicians have refused to clarify an unapproved abbreviation, McKee still. "When a physician is blatantly nonresponsive to a nurse’s request to clarify an unapproved abbreviation, the nurse is required to fill out a quality management memo and expeditiously deliver it to the chief nursing officer. Most of the physicians understand that the nurses are simply doing what is required by the hospital and JCAHO."
Weekly chart audits are done by the manager of each unit to search for use of these abbreviations and give feedback to staff having difficulty. "Also, the chief medical officer and the chief of staff take an active role in personally contacting physicians who are having greater difficulty with compliance, and that has helped quite a bit," she adds. "This has only been necessary about half a dozen times. The medical staff are usually very responsive to their superiors."
[For more information, contact:
• Kathy Brandeis, RN, BSN, Performance Improve-ment/JCAHO Coordinator, Saint Joseph’s Hospital of Atlanta, 5665 Peachtree Dunwoody Road N.E., Atlanta, GA 30342-1764. Phone: (404) 851-7506. Fax: (404) 851-5604. E-mail: firstname.lastname@example.org.
• Marie Gowdy, APRN-BC, Lead Clinical Nurse Specialist, NorthEast Medical Center, 920 Church St. N., Concord, NC 28025. Phone: (704) 262-4746. E-mail: email@example.com.
• Martha McKee, RN, MN, OCN, Oncology Mana-ger, Good Samaritan Hospital, 407 14th Ave. S.E., Puyallup, WA 98371-0192. Phone: (253) 848-6661. E-mail: firstname.lastname@example.org.]